Zwangerschap na gastric bypass, een moeilijk evenwicht
Roland Devlieger MD, PhDDepartment of Obstetrics and GynaecologyUniversity Hospitals Leuven, Belgium
Zwangerschap na bariatrie is:A. Af te radenB. Aan te bevelenC. Ik weet het niet
Overzicht• Bariatrische heelkunde
o Effect op gezondheido Effect op fertiliteito Effect op zwangerschap
• Aurora studie• Aanbevelingen voor klinische opvolging
“Venus in front of the mirror” PP Rubens, 1613
Overweight and Obesity figures have doubled since 1980
Chooi et al, Metabolism 2019
Women are affected more than men
Obesity in women of reproductive age
* WHO, 2016
Trend in number of procedures (IFSO)Angrisani et al. 2015
Obesity surgery
Up to 80% of the procedures are performed in women of reproductive age
Laparoscopic Gastric Bypass
Sjöström et al. NEJM 2007
Weight loss following bariatric surgery SOS study
BARIATRIC SURGERY
WEIGHT LOSS
IMPROVED FERTILITY
IMPROVED OVARIAN FUNCTION
↓MIS
IMPROVED SELF IMAGE
IMPROVED SEXUAL ACTIVITY
↓ADIPOSE TISSUE
↓ESTRADIOL ↓INSULIN
↑GnRH↑LH, FSH
↑SHBG
↓TESTOSTERONE
DECREASED CONTRACEPTIVE
EFFICACY
Abbreviations: FSH Follicular Stimulating Hormone, GnRH Gonadotropin Releasing Hormone, LH Lutenising Hormone, MIS Müllerian Inhibiting Substance, SHBG Sex Hormone Binding Globuline.
Effect on pregnancy?
Pregnancy outcomes following bariatric surgery
Same pre-operative BMI Same pre-pregnancy BMI
OR 0.21 (NNB 5)
Kwong et al, AJOG 2018
OR 2.3 (NNH 21)
20 cohort studiesN=8364
33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls.
• Pre/early-pregnancy BMI–matched controls (N=9)• Obese controls (N=14)
• ≥30 kg/m2, 35 kg/m2, or 40 kg/m2
• Matched for pre-surgery BMI• Pregnancies before and after bariatric surgery
(N=11)• General population (N=9) • Healthy BMI (N=5)
Perinatal mortality and congenital anomalies after bariatric surgery meta-analysis
Akhter Z, Rankin J, Ceulemans D, Ngongalah L, Ackroyd R, et al. (2019) Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLOS Medicine 16(8): e1002866. https://doi.org/10.1371/journal.pmed.1002866https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002866
NICU admission after bariatric surgery meta-analysis.
Akhter Z, Rankin J, Ceulemans D, Ngongalah L, Ackroyd R, et al. (2019) Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLOS Medicine 16(8): e1002866. https://doi.org/10.1371/journal.pmed.1002866https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002866
Pregnancy outcomes summary
Pregnancy outcomes Compared to pre-operative BMI Compared to pre-pregnancy BMI
Gestational diabetes mellitus ↘↘ =
Caeseaean section ? ↗
Pregnancy induced hypertension ↘ =
Pre-eclampsia / eclampsia ↘ =
Preterm delivery ↗ ↗
SGA/IUGR ↗↗ ↗
LGA/ macrosomia ↘↘ ↘
Perinatal mortality ↗ ↗↗
Obesity surgery
Nutritional deficienciesSurgical complications
Micronutrient deficiencies
Devlieger et al PLOS ONE 2014
• Small bowel obstruction due to internal herniation, volvulus, leak, …• Not unfrequent (2-11%)
High mortalityGuelinckx et al, Hum Reprod Update 2009 ; Wax JR et al, AJOG 2013
Delay in diagnosis and treatment• Symptomatology (abdominal pain, vomiting) frequent in
pregnancy• Diagnostic procedures delayed in pregnancy• Changed anatomy
Chirurgische complicaties
Fetal growth after bariatric surgery
Intrauterine growth restriction
• Growth index significantly lower in pregnant women with bariatric surgery compared to a control group of non-surgical pregnant women
• No influence interval surgery - pregnancy
Obesity surgery
Trajectories of Fetal Adipose Tissue Thickness in Pregnancies After Gastric Bypass Surgery Yerlikaya-Schatten et al, Obes Surg 2019
RYGB N=41 BMIm N=41 Obese N=61
• Decreased body weight• Decreased body fat• Decreased placental weight
Bariatric surgery mimics in-utero starvation
Long term health effects??
Bariatric Surgery
ObeseControl
Normal WeightControl
2009-2014Weight-loss
procedure
2006 -2008
2007-2008
2017-2019
6.5 ± 1.3 years
10.8 ± 0.3 years
10.6 ± 0.2 years
Prospective cross-sectional data collection: single home visit (trained paediatrician) Data on: Body composition, adiposity and metabolic profile
Vascular functionPsychomotor functioning and eating habits
N =36
N =71
N =36
Offspring after Bariatric Surgery present with least favorable body adiposity profile
Unpublished data 2019 – Van De Maele K, Bogaerts A, De Schepper J, Provyn S, Ceulemans D, Guelinckx I, Gies I* & Devlieger R*
Obese Control
Bariatric Surgery
Normal Weight Control
P < 0.001
Highest Waist/Height ratio
0.47 ± 0.06 0.43 ± 0.05 0.41 ± 0.04Obese
ControlBariatric Surgery
Normal Weight Control
P < 0.001
Highest body fat percentage excess by BIA
5.7 % ± 5.1 1.4 % ± 5.4 -0.1% ± 4.1
Obese ControlBariatric Surgery
Normal Weight Control
P = 0.04
0.61 ± 1.54 0.16 ± 1.09 -0.15 ± 1.12
Highest Waist SD score
The Aurora Study: a prospective cohort study
Surgery
Pregnancy and 6m postpartum
incl
usio
n
Online questionnaires
Blood sampling
incl
usio
n
The Aurora Study: current status on general characteristics
422 patients, 144 completed pregnancies
Age at inclusion: 29.8y ± 5.6
Gastric banding9%
RYGB83%
Biliopancreatic diversion
1%Sleeve
gastrectomie7%
BMI before surgery: 42.4kg/m2 ± 5.8 BMI at start of pregnancy: 28.4kg/m2 ± 5.6
Weight loss after surgery: 45.3kg ± 16.5 Weight gain during pregnancy: 12.5kg ± 6.4
The Aurora Study: current status on weight loss/gain
32% BMI>30
AURORA study:Birth Weight
Low birth weight (<2500g) present in 16.2%
Mean birth weight: 3080g ± 67
AURORA-study outputSubject Reference
Reviews Guelinckx et al, Hum Rep Update 2009Devlieger et al, AJOG 2011Akther et al, PLoS Med 2019
Protocols Jans et al, BMC Pregnancy Childbirth 2016Van de Maele et al, BMJ Ped Open 2019
Lifestyle Guelinckx et al, Obes Surg 2012
Neonatal complications Eerdekens et al, Eur J Ped 2010Van Mieghem et al, Obstet Gynecol 2010
Depression and anxiety Jans et al, Obes Surg 2018
Nutritional deficiencies Jans et al, SORD 2013Devlieger et al, PLoS-one 2015Jans et al, Adv Nutr 2015
Contraception and sexuality Luyssen et al, Obes Surg 2018
Surgical complications Devlieger et al, NEJM 2015Vannevel et al, Obstet Gynecol 2016
Screening for gestational diabetes Benhalima et al, Nutrients 2018
Breast feeding Jans et al, Obes Surg 2015Jans et al, J Nutr 2018
G id li Sh t l Ob R i 2019
Recommendations for periconception, antenatal and
postnatal care
Jill ShawUnited Kingdom
Dries CeulemansBelgium
Zainab AkhterUnited Kingdom
Karl NeffUnited Kingdom
Kathryn HartUnited Kingdom
Nicola HeslehurstUnited Kingdom
IztokŠtotlSlovenia
SanjayAgrawalUnited Kingdom
RegineSteegers-TheunissenThe Netherlands
ShahradTaheriQatar
BethGreensladeUnited Kingdom
Judith RankinUnited Kingdom
BobbyHudaUnited Kingdom
Isy DouekUnited Kingdom
SanderGaljaardThe Netherlands
OritBlumenfeldIsrael
Ann RobinsonUnited Kingdom
MartinWhyteUnited Kingdom
Elaine MathewsUnited Kingdom
Roland DevliegerBelgium
20 – 21 April 2017, University of Surrey, UK
Zwangerschap na bariatrie is:A. Af te radenB. Aan te bevelenC. Ik weet het niet
Bedankt!
Glucose metabolism during pregnancy after bariatric surgery
Van Beek et al. 2017
The risk of GDM after bariatric surgery
• BS diminishes the risk for GDM when compared to pre-surgery BMI matched controls
• But no effect is seen when compared to pre-pregnancy BMI matched controls
• As more than half of women after BS are still overweight or obese, the risk of GDM remains higher than in the normal population and screening for GDM is advised. (Alatishe et al. 2013.)
OGTT in pregnant women after bariatric surgery
Adverse events due to dumping in 65% of patients undergoing OGTT after BS (Andrade et al. 2016)
Pregnant women after RYGB had lower fasting glucose levels, but had more often a high glucose excursion at 1 h and 55% had a reactive hypoglycaemia at 2 h. (Feichtinger et al. 2016)
Reactive hypoglycaemia is associated to SGA (11.9 vs. 1.7%)(Rottenstreich et al, 2018)
Bariatric Normal weight
ObeseBMI matched
Benhalima et al, Nutrients 2018
Screening for DM/GDM after RYGB
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